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1773 Serpentine DrCITY OF EAGAN Remarks Sew & wtr permits and Addition Cedar Grove #6 Lot 7 Blk 5 Parcel 10 16705 070.05 Owner i , - , Street 1.773 Serpentine Dr. State Eagan-, MN 55122 i Improvement Date Amount Annual Years Payment Receipt Date STREET SURF. STREET RESTOR. GRADING SAN SEW TRUNK # SEWER LATERAL 1970 1472-00 paid WATERMAIN WATER LATERAL 1970 9n WATER AREA # STORM SEW TRK 1270 STORM SEW LAT CURB & GUTTER SIDEWALK STREET LIGHT WATER CONN. 210- On 1519 A 7 - 6 9 BUILDING PER. - - - SAC 200.00 1519 6-27-69 PARK INSPECTION RECORD CITY OF EAGAN PERMIT TYPE: I. t u T N1i 3830 Pilot Knob Road Permit Number: Eagan, Minnesota 55122-1897 Date Issued: (612) 681-4675 SITE ADDRESS: APPLICANT: :I i N 1 1 Nt 1)h I. r i11'N( (r 1 Nt. .! PERMIT SUBTYPE: . I (6IZ) 6.33--iN4 TYPE OF WORK: At II HAI JON NA', T 11`J K T f AA : I IN[ 1)11;CNTPT ION 4 V F J Permit No. Permit Holder Date Telephone • ELECTRIC PLUMBING HVAC inspection Date Insp. Comments FOOTINGS FOUND FRAMING ROOFING ROUGH PLUMBING PLBG AIR TEST ROUGH HEATING GAS SVC TEST INSUL GYPBOARD FIREPLACE z6Z FIREPLACE AIR TEST FINAL PLBG FINAL HTG ORSAT TEST BLDG FINAL BSMT R.I. BSMT FINAL DECK FTG DECK FINAL EAGAN TOWNSHIP BUILDING PERMIT Owner ......r2w .................. -------------- . Address (present) .•?r.Y.?:------- ? ."' -----Sln' ?-' .................. Builder Address N° 204'7 Eagan Township Town Hall Date ...... ..!'-/°1.7:(.6:.7 ............... Sioxies To Be Used For Front Depth Heigh! Est. Cost Permit Fee Remarks LOCATION or a (!. , "? . (' This permit does not authorise the use of streets, roads, alleys or sidewalks nor does it give the owner or his agent the right to create any situation which is a nuisance or which presents a hazard to the health, safety, convenience and general welfare to anyone in the community. THIS PERMIT MUST BE KEPT ON THE PREMISE WHILE THE WORK IS IN PROGRESS. This is to certify, that... [ ... ,ra7t.;, ...has permission to erect a._r ...... ...... ................?.p .../.... upon the above described premise subject to the provisions of the Building Ordinance for Eagan Township adopd April 11, 1955. / ...................... ..,.._ IC?C;c..??.-: ............. Per ....................G?c?s :3a"'.... f.:.:: ty.._._.................-----........... .- . l Building Inspector ' Chaim of Tnwn Board - (. a3 S CITY USE ONLY PERMIT #: RECEIPT DATE: ?° //b L 8008 RESIDENTIAL MECHANICAL PERMIT APPLICATION CITY OF EASAP 3830 PILOT KNOB HD EAa" MN 55122 651-691-4675 Please complete for: ? single family dwellings townhomes and condos when permits are required for each unit Date: 5-17-02- SITE ADDRESS: I r-7 ?7,5 Ser hen-) OWNER NAME: Y-V ? - gym TELEPHONE* 4r 4- C°2'DS 7 INSTALLER NAME: STREET ADDRESS: Wohlers Southside Htg. & Air., Inc. 6950 W. 146' St., 9106 Apple Valley, MN _5512.4- (952) 431-7099 CITY: STATE: ZIP: Place a check mark next to the permit work type Add-on, modification or alteration to existing dwelling unit $ 30.00 • fumace replacement • air exchanger • air conditioner • other Nature ofwork:P, ej?a c-Q--RL?ROCs Y1e E (O, Cx?TLL s r1cS?Q C-?? tc? 70. L?SC? ? 1??1rnC??-1 Cfl ?? _ I71? ; Ci T? 2 Ir???ta D State Surcharge $ 50 Total SIGNATURE OF PERMITTEE 1/02 CITY USE ONLY PERMIT #: :. =n1 RECEIPT DATE: APPROVED BY: INSPECTOR 8008 COMMERCIAL MECHANICAL PERMIT APPLICATION CITY OF EAGAN 3630 PILOT KNOB RD EA6AN, MN 551 EE 651-681-4675 Please complete for: all commerciaUndustrial buildings multi-family buildings when separate permits are not required for each dwelling unit DATE: SITE ADDRESS: OWNER NAME: PHONE #: TENANT NAME (IMPROVEMENTS ONLY): WAS THERE A PREVIOUS TENANT IN THIS SPACE? Y N. NAME: INSTALLER: STREET ADDRESS: CITY: STATE: ZIP: TELEPHONE #: WORK TYPE: New construction Install U.G. Tank - Interior Improvement Remove U.G. Tank Processed Piping Specify Nature of Work: When installing/removing underground tank, call 651-681-4675 for inspection by Fire Marshal and Plumbing inspector. Fees: 1% of contract price OR $50.00 minimum fee, whichever is greater. Underground tank removal/installation = minimum fee Contract price: $ x l% = $ (Base Fee) State surcharge calculate at $.50 for each $1,000 Base Fee TOTAL $ SIGNATURE OF PERMITTEE Updated 1/02 RESIDENTIAL BUILDING PERMIT APPLICATION CITY OF EAGAN 3830 PILOT KNOB RD - 55122 651-681-4675 New Construction Requirements • 3 registered site surveys showing sq. ft. of lot, sq. ft. of house; and all roofed areas (20% maximum lot coverage allowed) 2 copies of plan showing beam & window sizes; poured found design, etc.) • 1 set of Energy Calculations 3 copies of Tree Preservation Plan if lot platted after 711/93 • Rim Joist Dated Options selection sheet (bldgs with 3 or less units) DATE ? /`0 JOB SITE ADDR IF MULTI-FAMILY BUILDING, HOW MANY UNITS? PROPERTY OWNER cSNEJ?LUr _WE5MI TYPE OF WORK L.ZI ICJ "R<k, X APPLICANT ?I? +?tPt'KVU, 1 ADDRESS ?D A III N• PAGER # FIREPLACE(S) -0-1 -2 PHONE# /-SZD-96_? y1 ZIP CODE _??UJQ- CELL PHONE # 40? FAX # VIEW RESIDENTIAL BUILDING ONLY - FILL OUT COMPLETELY Energy Code Category _ MINNESOTA RULES 7670 CATEGORY I (check one) - Residential Ventilation Category 1 Worksheet Sut - Energy Envelope Calculations Submitted MINNESOTA RULES 7672 New Energy Code Worksheet Submitted Plumbing Contractor: _ Plumbing System Includes: Mechanical Contractor: _ Mechanical System Includes: Sewer/Water Contractor: Water Softener _ Water Heater No. of Baths Air Conditioning Heat Recovery System Phone # Fee: $70.00 All above information must be submitted prior to processing of application. I hereby acknowledge that I have read this application, state that the information is correct, and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Signature of Applicant s 4? Certificates of Survey Received _ Tree Preservation Plan Received _ Not Required _ Updated 2002 DO RemodellReoair Requirements 2 copies of plan 1 set of Energy Calculations for heated additions 1 site survey for exterior additions & decks Indicate if home served by septic system for additions VALUATION /V. _ Phone Lawn Sprinkler No. of R.I. Baths Phone # Fee: $90.00 OFFICE USE ONLY s ? 01 Foundation ? 07 05-plex ? 13 16-plex ? 20 Pool ? 30 Accessory Bldg ? 02 SF Dwelling ? 08 06-plex ? 16 Fireplace ? 21 Porch (3-sea.) ? 31 Ext. Alt - Multi ? 03 01 of _ plex ? 09 07-plex ? 17 Garage ? 22 Porch/Addn. (4-sea.) ? 33 Ext. Alt - SF ? 04 02-plex ? 10 08-plex ' ? 18 Deck ? 23 Porch (screened) ? 36 Multi ? 05 03-plex ? 11 10-plex ? 19 Lower Level ? 24 Storm Damage ? 06 04-plex ? 12 12-plex Plbg_Y or - N ? 25 Miscellaneous ? 31 New ? 35 Int Improvement ? 38 Demolish (Interior) ? 44 Siding ? 32 Addition ? 36 Move Bldg. ? 42 Demolish (Foundation) ? 45 Fire Repair ? 33 Alteration ? 37 Demolish (Bldg)' ? 43 Reroof ? 46 Windows/Doors ? 34 Replacement "Demolition (Entire Bldg only) - Give PCA handout to applicant Valuation Occupancy MC/ES System Census Code Zoning City Water SAC Units Stories Booster Pump Nbr. of Units Sq. Ft. PRV Nbr. of Bldgs Length Fire Sprinklered Type of Const Width REQUIRED INSPECTIONS - Footings (new bldg) _ Finai/C.O. _ Footings (deck) _ Final/No C.O. - Footings (addition) _ Plumbing Foundation _ HVAC - Drain Tile Other Roof _ Ice & Water _ Final - Figs _ Air/Gas Tests Pool Final - Framing _ _ Stucco _ Stone Siding _ Fireplace _ R.I. - Air Test - Final _ _ Windows (new/replacement) Insulation - _ Retaining Wall A Approved By , Building Inspector Base Fee Surcharge Plan Review MC/ES SAC City SAC Water Supply & Storage S&W Permit & Surcharge Treatment Plant Plumbing Permit Mechanical Permit License Search Copies Other Total S-?k S.SID RESIDENTIAL BUILDING PERMIT APPLICATION CITY OF EAGAN 3830 PILOT KNOB RD - 55122 651-681-4675 New Construction Requirements • 3 registered site surveys showing sq. ft. of lot, sq. ft. of house; and all roofed areas (20% maximum lot coverage allowed) • 2 copies of plan showing beam &window sizes; poured found design, etc.) • 1 set of Energy Calculations • 3 copies of Tree Preservation Plan if lot platted after 7/1193 • Rim Joist Detail Opfions selection sheet (bldgs with 3 or less units) DATE /n JOB SITE IF MULTI-FAMILY BUILDING, HOW MANY UNITS? F VP PROPERTY OWNER S -PLY (A)e5-TRLU91 TYPE OF WORK yr/? Vt ???17 FIREPLACE(S) _ 0 _ 1 _ 2 APPLICA ADDRESS PAGER # NEW RESIDENTIAL BUILDING ONLY - FILL OUT COMPLETELY Energy Code Category _ MINNESOTA RULES 7670 CATEGORY I (check one) Residential Ventilation Category 1 Worksheet Submitted Energy Envelope Calculations Submitted MINNESOTA RULES 7672 - New Energy Code Worksheet Submitted CELL PHONE # FAX # Plumbing Contractor: Plumbing System Includes: Mechanical Contractor: _ Mechanical System Includes: Sewer/Water Contractor: Phone # Phone # Fee: $90.00 FCC: $70.00 All above information must be submitted prior to processing of application. I hereby acknowledge that I have read this application, state that the information is correct, and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordina?nc-es. Signature of Applicant ??'?- Oc?G.7 h.? NT IG? NONTS WV WU• PHONE41lAW-- i2?6??yyS`?? PAS 1 ?SS?D JAWJ49.ALn AVIE. N- YtTAC. , MIJ ZIP CODE Water Softener Water Heater No. of Baths RemodellReoair Requirements • 2 copies of plan • 1 set of Energy Calculations for heated additions 1 site survey for extedor additions & decks Indicate if home served by septic system for additions aC' VALUATION I Phone Lawn Sprinkler No. of R.I. Baths Air Conditioning Heat Recovery System Certificates of Survey Received _ Tree Preservation Plan Received _ Not Required _ Updated 2002 OFFICE USE ONLY ? 01 Foundation ? 07 05-plex ? 13 16-plex ? 20 Pool ? 30 Accessory Bldg ? 02 SF Dwelling ? 08 06-plex ? 16 Fireplace ? 21 Porch (3-sea.) ? 31 EM. Alt - Multi ? 03 01 of-plex ? 09 07-plex ? 17 Garage ? 22 Porch/Addn.(4-sea.) ? 33 Ext. Alt - SF ? 04 02-plex ? 10 08-plex ? 18 Deck ? 23 Porch (screened) ? 36 Multi ? 05 03-plex ? 11 10-plex ? 19 Lower Level ? 24 Storm Damage ? 06 04-plex ? 12 12-plex Plbg_Yor- N ? 25 Miscellaneous ? 31 New ? 35 Int Improvement ? 38 Demolish (Interior) ? 44 Siding ? 32 Addition ? 36 Move Bldg. ? 42 Demolish (Foundation) ? 45 Fire Repair ? 33 Alteration ? 37 Demolish (Bldg)" ? 43 Reroof ? 46 Windows/Doors ? 34 Replacement "Demolition (Entire Bldg only) - Give PCA handout to applicant Valuation Occupancy MC/ES System Census Code Zoning City Water SAC Units Stories Booster Pump Nbr. of Units Sq. Ft. PRV Nbr. of Bldgs Length Fire Sprinklered Type of Const Width REQUIRED INSPECTIONS Footings (new bldg) _ Final/C.O. - Footings (deck) _ Final/No C.O. _ Footings (addition) _ Plumbing _ Foundation _ I-IVAC _ Drain Tile Other Roof _ Ice & Water _ Final - Pool _ Ftgs _ Air/Gas Tests _ Final - Framing - Siding _ Stucco _ Stone - Fireplace - R.I. - Air Test - Final Windows (new/replacement) - Insulation - _ Retaining Wall Approved By , Building Inspector Base Fee Surcharge Plan Review MC/ES SAC City SAC Water Supply & Storage S&W Permit & Surcharge Treatment Plant Plumbing Permit Mechanical Permit License Search Copies Other Total CITY OF: ...A&AN 7a iL%i?/9E,Y'TNI a4.4`^D'i 4 of q!..L...f.l: i F: Cr,'F`a Cp f.NC 7INIE ;.t]0 ?}'6: 531.10.1. I. i' 3 FIi F.PENT':i:Nl 50 CITY OF EAGAN 3830 Pilot Knob Road Eagan. Minnesota 55122-1897 (612) 681-4675 PERMIT PERMIT TYPE: BUILDING Permit Number: 0 2 9 0 6 8 Date Issued: 10/17/96 SITE ADDRESS: P.I.N.: 10-16705-070-05 1773 SERPENTINE DR LOT: 7 BLOCK: 5 CEDAR GROVE #6 DESCRIPTION: .GAS INSERT/GA? BGilding,.,Permit Type Building Wp,rk Type ode `.1 434 Census Code' ? I C J.. t? ` x t .w %t t r' LINE FIREPLACE ALTERATION ALT. RESIDENTIAL t REMARKS: FEE SUMMARY: Base Fee Surcharge Total Fee 1 $25.00 $.50 $25.50 CONTRACTOR: - Applicant - ST. LIC OWNER: FIRESIDE CORNER INC 16331042 0001068 WESTRUM SHIRLEY 2700 N FAIRVIEW AVE 1773 SERPENTINE DR ROSEVILLE MN 55113 EAGAN MN 55122 (612) 633-1042 (612)890-9760 I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State of Mn. Statutes and City of Eagan Ordinances. t ?rxin R "I f11 AP LICANTiPE I EE IG ATURE ISSUED : SI ATUR CITY OF EAGAN 3830 PILOT KNOB RD - 55122 q f, JD Iq 0 L t 1996 FIREPLACE PERMIT APPLICATION d`J /? 681-4675 DATE: art 1-7111 /?/& DESCRIPTION OF WORK: _ CONSTRUCT NEW FIREPLACE: WOOD BURNING _ GAS -K INSTALL GAS INSERT ONLY IN EXISTING FIREPLACE INSTALL GAS LINE ONLY IN EXISTING FIREPLACE OTHER: ROOM TO BE INSTALLED IN: E L, A 6A, 40 (I) P yr /. P L/ 0 I STREET ADDRESS: - LOT BLOCK 2?3 CI . I J? SUBD./P.I.D. #: OWNER CONTRACTOR APPLICANT: (circle one only) I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. PROPERTY OWNER FIREPLACE INSTALLER Name: r Q In (d. ) E I AIM Phone #: iw U- '7(0 Signature: Street Address: City: (, C{ DI lit ti State: Mp. Zip: Company: w 5l'cf oli-eteSi`re &-twPhone #: 33" ?57° Signature: Street Address: U). Owa 1-3 City: 13 fit y 11 S C/! 4L State: 2ML' License #: zz? Zip: GAS LINE Company: -Eft e as 6& olo3M//0 Phone #: INSTALLER Name: Signature: _ Street Address: City: State: Zip: OFFICE USE ONLY BUILDING PERMIT TYPE ? 14 Fireplace WORK TYPE ? 31 New ? 33 Alterations ? 32 Addition ? 34 Repair GENERAL INFORMATION Census Code. SAC Code REMARKS p Chimney/flue must be inspected before concealing. N MEMO -city of eagan TO: DIANE DOWNS, UTILITY BILLING CLERK FROM: ED KIRSCHT, SR. ENGINEERING TECH DATE: AUGUST 25, 1993 SUBJECT: STREETLIGHT ENERGY COSTS CEDAR GROVE NO. 6 (141 LOTS) This memo is to inform your department to begin to invoice the energy costs at the single family rate effective August 1, 1993 to the property owners in Cedar Grove No. 6 Addition as listed below: TOTAL 141 The City is currently being billed by Dakota Electric for streetlighting in the above listed subdivision. Ed Kirscht Sr. Engineering Tech cc: Mike Foertsch, Asst. City Eng. Block 1, Lots 1 1 Block 2, Lots 1-8 8 Block 3, Lots 1-18 18 Block 4, Lots 1-11 11 Block 5, Lots 1-9 9 Block 6, Lots 1-53 53 (Lots 54 through 61, Block 6, should not be billed at this time) Block 7, Lots 1-12 12 Block 8, Lots 1-18 18 Block 9, Lots 1-11 11 EK/je r EAGAN TOWNSHIP 3795 Pilot Knob Road St. Paul, Minnesota 55111 Telephone 454-5242 PERMIT FOR WATER SERVICE CONNECTION Date: June 20, 1969 Billing Name: Cedar Grove Const. Co. Owner: Cedar Grove Cpnst. Cq. Plumber: Stein. Inc. Number: 24 '7 -.S- - ?Q Site Address: 1773 Serpentine Billing Address7343 Concord Blvd. E. ion Meter No, Permit Fee 7_5n „d. Meter Reading I Meter Dep. Meter Sealed: Yes_ lAdd'l Chg. NO I Total Chg. Building is a: Residence X Multiple No. Units Commercial Industrial Other Inspected by Date Remarks: By: Chief Inspector In consideration of the issue and delivery to me of the above permit, I hereby agree to do the proposed work in accordance with the rules and regulations of Eagan Township, Dakota County, nneaota. 11 ra: By: ! - Please notify the above office when ready for inspection and connection. EAGAN TOWNSHIP 3795 Pilot Knob Road St. Paul, Minnesota 55111 Telephone 454-5242 PERMIT FOR SEWER SERVICE CONNECTION DATE: June 20, 1969 OWNER: Cedar Grove Const. Co PLUMBER Stein, Inc. NUMBER 42-1 Address 1773 Sepentine -7;S b TYPE OF PIPECebt Iron DESCRIPTION OF BUILDING Industrial Commercial Residential Multiple Dwelling No, of units x Location of Connections: Connection Charge 200.00 pd. Permit Fee 7.50 Pd. Street Repairs Total inspected by: Date Remarks: By Chief Inspector In consideration of the issue and delivery to me of the above permit, I hereby agree to do the proposed work in accordance with the rules and regulations of Eagan Township, Dakota County Minnesota By / Please notify when ready for inspection and connection and before any portion of the work is covered. PERMIT City of Eagan Permit Type:Building Permit Number:EA118088 Date Issued:10/28/2013 Permit Category:ePermit Site Address: 1773 Serpentine Dr Lot:7 Block: 5 Addition: Cedar Grove 6th PID:10-16705-05-070 Use: Description: Sub Type:Reroof Work Type:Replace Description: Census Code:434 - Zoning: Square Feet:0 Occupancy: Construction Type: Comments:Please print pictures of ice and water protection and leave on site. Carbon monoxide detectors are required by law in ALL single family homes . Barbara Bessent Fee Summary:BL - Base Fee $4K $103.25 0801.4085 Surcharge - Based on Valuation $4K $2.00 9001.2195 $105.25 Total: I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Contractor:Owner:- Applicant - Shirley A Westrum 1773 Serpentine Dr Eagan MN 55122 Minnesota Exteriors 8600 Jefferson Hwy Osseo MN 55369 (763) 391-5514 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA118262 Date Issued:10/30/2013 Permit Category:ePermit Site Address: 1773 Serpentine Dr Lot:7 Block: 5 Addition: Cedar Grove 6th PID:10-16705-05-070 Use: Description: Sub Type:Reroof Work Type:Replace Description: Census Code:434 - Zoning: Square Feet:0 Occupancy: Construction Type: Comments:Please print pictures of ice and water protection and leave on site. Carbon monoxide detectors are required by law in ALL single family homes . Tammy Donner Valuation: 4,000.00 Fee Summary:BL - Base Fee $4K $103.25 0801.4085 Surcharge - Based on Valuation $4K $2.00 9001.2195 $105.25 Total: I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Contractor:Owner:- Applicant - Shirley A Westrum 1773 Serpentine Dr Eagan MN 55122 Ashco Exteriors Inc 11164 Zealand Ave N Champlin MN 55316 (763) 225-8333 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA119644 Date Issued:12/10/2013 Permit Category:ePermit Site Address: 1773 Serpentine Dr Lot:7 Block: 5 Addition: Cedar Grove 6th PID:10-16705-05-070 Use: Description: Sub Type:Siding Work Type:Replace Description: Census Code:434 - Zoning: Square Feet:0 Occupancy: Construction Type: Comments:Please leave printed pictures of house wrap on site for the final inspection. When installing ventilated soffit material, remove existing material (i.e. debris that could block vents) and take steps to ensure maximum ventilation to attic. Call for final inspection after installation. Valuation: 4,000.00 Fee Summary:BL - Base Fee $4K $103.25 0801.4085 Surcharge - Based on Valuation $4K $2.00 9001.2195 $105.25 Total: I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Contractor:Owner:- Applicant - Shirley A Westrum 1773 Serpentine Dr Eagan MN 55122 Ashco Exteriors Inc 11164 Zealand Ave N Champlin MN 55316 (763) 225-8333 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA120121 Date Issued:01/17/2014 Permit Category:ePermit Site Address: 1773 Serpentine Dr Lot:7 Block: 5 Addition: Cedar Grove 6th PID:10-16705-05-070 Use: Description: Sub Type:Windows/Doors Work Type:Replace Description:One Window/Door Census Code:434 - Zoning: Square Feet:0 Occupancy: Construction Type: Comments:Improvements to the home require smoke detectors in all bedrooms. If altering window openings or installing Bay or Bow windows, call for framing inspection. Call for final inspection after installation. Carbon monoxide detectors are required by law in ALL single family homes . Valuation: 500.00 Fee Summary:BL - Base Fee $500 $40.00 0801.4085 Surcharge - Based on Valuation $500 $0.50 9001.2195 $40.50 Total: I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Contractor:Owner:- Applicant - Shirley A Westrum 1773 Serpentine Dr Eagan MN 55122 Ashco Exteriors Inc 11164 Zealand Ave N Champlin MN 55316 (763) 225-8333 Applicant/Permitee: Signature Issued By: Signature